Your Dental Benefits Through HealthCare.gov

Payment Form

We are glad you are here.

Thank you for choosing Dental Health Services through HealthCare.gov. To complete your enrollment, you must submit your binder payment. You can submit your personal and plan information here and set up your ongoing payment arrangements on the next page. When you click the "Submit" button at the bottom of the page, you will be taken to Instamed, our secure payment website.

It is important to enter the birthdates of all enrollees on the plan below the "Payment Information" section. This will ensure your card is charged the correct amount by Instamed.

Subscriber Information

First Name:
Last Name:

Subscriber Number (optional):

Exchange Subscriber ID (optional):

Mailing Address:

City:

State:
Zip Code:

Email:

Phone Number:

Your Selected Dentist Number:

Don't know which dentist to select yet? Not to worry! You can always log into your member portal and complete this step later

Moon Photo Lab

IMPORTANT: Can you read this? If not, we can have somebody help you read it. You may also be able to get this information written in your language. For free help, please call right away at 1-866-756-4259. Dental Health Services has a toll free TTY line 1-888-645-1257 for the hearing and speech impaired.